Spastic Constipation

( Originally Published 1940 )

SPASTIC constipation, a disorder in the function of the colon, is very common, and is often accompanied by fatigue and "nervousness." The disturbance in function is often the most dramatic element in the living pattern of the patient, but it is only one element and, from the medical point of view, often not the most important. Fatigue and nervous irritability may even overshadow the constipation.

A person with spastic constipation usually has irregular bowel evacuations. For a few weeks the bowel may move regularly every day or every second day. Then a change in the rhythm occurs and evacuations appear once in three days, or even once a week, followed by evacuations occurring five to ten times a day. When the stools are infrequent, they are often like pellets and may be covered with slime or mucus. Between stool evacuations there may be passage of mucus. When the evacuations are frequent, the stools are watery and may be mixed with mucus.

In spastic constipation there are, as a rule, pains in the abdomen and attacks of gas and distention, associated with fatigue and emotional disturbances. Careful physical examination of a person troubled by spastic constipation will generally yield no evidence of an organic disorder. The person may be underweight and nervous, and the abdomen may be sensitive to the pressure of the doctor's hands, but no further disturbances are obvious. X-ray examination of the digestive tract shows that the colon is in a state of spasm-parts or all of the colon are contracted so that the passageway is reduced. The colon is in a condition of marked irritability, abnormally sensitive to the slightest stimulation. It is for this reason that the condition of spastic constipation has also been termed "irritable colon." Both terms, however, are unsatisfactory, since they refer solely to the state of the colon, which is only one of the organs affected. Spastic constipation or "irritable colon" is really a nervous disorder in which the colon acts as a barometer of nervous changes. The key to the understanding of this condition is the whole pattern of emotional reactions that make up the individual personality.

It is in the direction of personality studies that we must look for the solution of the problem of spastic constipation. The most promising work is being done where physicians are working in cooperation with psychiatrists. The physician selects the cases to be studied and makes certain that no organic disease is present. The psychiatrist then evaluates the personality of the patient, finds out what are his particular problems, and tries to discover the causes and methods of operation of the emotional reactions. By such cooperative work the patient is enabled to have a better insight into his own personality and to understand the causes of many of his symptoms. He begins to appreciate that the constipation, diarrhea, and abdominal pain are not simply symptoms of a disorder of the colon, but rather that they are a dramatic way in which one organ, the-c, expresses his general nervous instability and irritability.

Doctors are beginning to see that the interaction of environment and personality has a special importance in the development of spastic constipation and other nervous disorders, that social conditions have a powerful influence on the behavior of people. Living and working conditions can determine whether a person who has a tendency to spastic constipation or some other nervous disorder will be acutely troubled by the disorder or relatively, free of symptoms. Where there is economic security and an opportunity for normal satisfaction of the instincts and desires, there are fewer cases of functional nervous disorders. But where social and economic conditions breed anxiety and frustration, there are more and severer cases of functional nervous disorders.

Treatment must not be directed solely toward bowel hygiene or the prescription of a laxative drug. The personality of the patient must also be studied, and the anxieties and frustrations of modern life must be considered and solved, so far as possible.

Laxatives and cathartics should be avoided. The intestine, like the nervous system, is in a state of irritability and very sensitive to the effect of stimulants. Just as when the hand is inflamed one would never think of bumping it against a hard surface, so one must not irritate the already irritated colon by taking a laxative. The only exception, perhaps, is the salt-water drink or agar. The latter, as de-scribed in Chapter XIII, is bland and non-irritating and may be taken in 2- to 4-teaspoonful doses daily. Mineral oil is generally unsatisfactory because of the tendency to leakage and formation of gas, although some people with spastic constipation find it helpful.

The diet should be well balanced, adequate and tasty. It should also be free, to a large extent, of irritating bulk or roughage. The digestive tract is in a state of irritability—or nervousness, if you. will—and must be spared the work or irritation that a bulk-producing diet imposes. A smooth diet is the best. This does not mean only milk and toast. Milk occasionally causes "indigestion," and there are some people who can't drink a glass of it without getting an attack of gas, abdominal cramps or diarrhea. There are a great many other foods available that are smooth and healthful. The following are some of the instructions that Dr. Walter C. Alvarez of the Mayo Clinic has found useful in the dietary treatment of patients with spastic constipation:

"This [smooth] diet is based not only on practical experience, but on a number of scientific principles. We have no ferment in our digestive tracts to dissolve cellulose, that is, the fibrous part of vegetables and fruits. Most of this material is quite indigestible, and if we eat much of it we throw a heavy burden on the bowel. This fiber interferes with the digestion of starches and predisposes to flatulence [gas].

"If there happen to be narrow or irritated places in the bowel, or kinks and adhesions, the fiber may cause clogging and back pressure. The ideal diet in such conditions is one which leaves only a small liquid residue which can trickle past the obstructions; in this way it will often give prompt relief. This smooth diet is indicated also when the bowel is irritated, overly active, and responsive to every stimulus.

"It should be tried out faithfully at first and then if it works well, other foods may be experimented with, one at a time. You may have learned by experience that some of the foods allowed on this list are hurtful to you; in that case

`If you are to give this diet a fair trial, eat no coarse foods' w h fiber, skins, seeds, or gristle. Avoid particularly salads with celery, tomatoes, cucumbers and pineapple, many of the green vegetables, raisins, berries, jams full of seeds, nuts, and many of the raw fruits (pineapple, apple, plums). Beans, cabbage, onions, green or red peppers, melons, cucumbers, and peanuts are notoriously gassy. If you are living in a boarding house you can stick to this diet by simply avoiding the for-bidden foods and eating more of the digestible ones which are put before you.

"Avoid sugar in concentrated form and take no candy or other food between meals. Hot cakes and waffles might not be bad if they were not eaten with so much syrup. Fried foods are not bad if they are properly fried, that is, totally immersed in fat at the right temperature. Avoid eating when in a rush and when mentally upset. Family rows should take place away from the table. Chewing gum may cause distress, as much air is swallowed with the saliva. Digestion is greatly helped by a good chewing surface. If there are any gaps in your teeth have your dentist fill them with bridges...."

It should be remembered that diet is not the be-all and end-all in treatment of spastic constipation. It is only a part of the treatment, the purpose of which is to minimize the shocks that the body has to bear in daily life. A smooth diet simply makes the work of the digestive tract easier. However, no matter how smooth the diet, if the nerves are frayed every day by the shocks of difficult living, the colon as well as the other organs may react with various symptoms. A proper diet is simply a useful adjunct to the broad program of treatment that attempts to adjust the personality difficulties and ease the environmental stresses.